Primary Care in Mental Health Settings

Primary Care in Mental Health Settings Anna Ratzliff, MD, PhD Jürgen Unützer, MD, MPH, MA With contributions from: Wayne Katon MD, Benjamin Druss, MD,...
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Primary Care in Mental Health Settings Anna Ratzliff, MD, PhD Jürgen Unützer, MD, MPH, MA With contributions from: Wayne Katon MD, Benjamin Druss, MD, MPH, Lori Raney, MD, John Kern, MD Supported by funding from the Center for Integrated Health Solutions

The SAMHSA/HRSA Center for Integrated Health Solutions

Providing information, experts, and resources dedicated to behavioral health and primary care integration Online: Phone: 202-684-7457 Email: [email protected]

Why primary care service to mental health populations? • High rates of physical illness in mentally ill • Premature mortality • Low quality of medical care to patients with mental illness • High expense of physically ill with mental illness • Access problems

Comorbidity of Mental Disorders and Medical Conditions

Mental Disorders and Medical Comorbidity by Druss BG and Reisinger Walker E:( Original data from National Comorbidity Survey Replication, 2001-2003

Monthly Expenditures for Chronic Conditions With and Without Comorbid Mental Illnesses

Mental Disorders and Medical Comorbidity by Druss BG and Reisinger Walker E:( Original data from Adapted from Melek and Norris (2005 Marketscan data)

Mortality Burden of Mental Disorders

Mental Disorders and Medical Comorbidity by Druss BG and Reisinger Walker E:( Original data from Adapted from Eaton et al., 2008 (literature review)

Increased Mortality • It is well established that persons with mental illness experience excess mortality compared with the general population •Compared to the general population, persons with major mental illness typically lose more than 25 years of normal life span. (Lutterman , 2003) •In Finland difference in life expectancy of was 25 years less than that of compared with a person in the general population (32.5 years vs. 57.5 years, respectively. (Tiihonen, 2009) •Persons with mental disorder die on average of 8.2 years earlier than the rest of the population (Druss, 2011 )

•While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases. (Parks, 2006)

Proposed Causes of Increased Mortality

Modifiable Risk Factors: Smoking, Weight and Inactivity

Social isolation

Unemployment/ Poverty

Lack of access to care

Medications/ Polypharmacy

Separation of medical and mental health

Non-Treatment of Medical Comorbidity: CATIE data

Rates of non-treatment 30.2% for diabetes,

Nasrallah HA et al, 2006

62.4% for 88.0% for hypertension dyslipidemia.

Changing Approach to Medical Care:

Barriers to Providing Primary Health Care to Psychiatric Populations Cultural



• Mental health staff and patients not used to incorporating primary care as part of job.

• Very rarely funded. • Billing medical services challenging.

• Population health issues not of interest to individual patients. • Specialists do not cross boundaries



• Devoting space, time, and money.

• Proximity is crucial. • Arm’s length is best.

Mental Disorders are Rarely the Only Health Problem Chronic Physical Pain

Cancer 10-20%

25-50% Smoking, Obesity, Physical Inactivity

Patientcentered care?

Mental Health / Substance Abuse

Neurologic Disorders 10-20%

40-70% Heart Disease




So, what do we do now?

Working Together: Many Possibilities! Site of Care Delivery

Primary Care Setting

Mental Health Setting


• Facilitated referral from mental health center

How Care Delivered

• On-site primary care provider • Primary care by psychiatrists

Working Together: A Team Approach PCP


Care Manager

Case Manager

Core Team


Other Behavioral Health Clinicians Substance Treatment Vocational Rehabilitation Other Community Resources

Other Resources

Roles for the Psychiatrist Co-Management • Each provider has their own caseload • PCP manages all medical problems • Psychiatrist manages all mental health problems • Work together to reenforce treatment plans

Manage with Primary Care Consult • Psychiatrist works with a care manager • Manages a caseload of patients for BOTH mental health and basic medical health concerns using protocols from PCP • PCP available for consultation and stepped care as needed

Comprehensive Management • Typically dually trained psychiatrist • Provider manages both medical and mental health problems • Limited number of providers have this expertise

All psychiatrists are responsible for “not making people sicker”.

Experimenting: Some models developed so far • • • • • • •

PCARE study (Druss et al, 2010) Inpatient team with internist (Rubin et al,2005) Facilitated referral to primary care (Griswold et al 2010) Care Management - “Hot Spotters” TEAMcare (Katon et al, 2010) Missouri Medicaid Health Homes – PC and CMHC’s VA Programs - Three Efforts: enhanced care coordination, care manager to SMI patients and PC presence within SMI

Experimenting: Some models developed so far • PCARE study Nurse care managers provided communication and advocacy to overcome barriers to primary medical care. (Druss, 2010) • Intervention group received more recommended preventive services, higher proportion of evidence-based services for cardiometabolic conditions, more likely to have a primary care provider (71.2% versus 51.9%).

• Inpatient program randomized patients to care with traditional psychiatric team vs team with internist (Rubin et al,2005) • Inclusion of internist resulted in improved process and health maintenance care

• Facilitated referral to primary care randomly assigned patients to a navigator for referrals versus usual care (Griswold et al 2010) • Intervention group was statistically more likely to access care, versus controls

Other Program Examples and Ideas • TEAMcare (Katon et al, 2010) • A Program for Managing Depression, Diabetes and Coronary Heart Disease in Primary Care. • Covers SMI to the extent that they are seen in primary care setting.

• Missouri Medicaid Health Homes – PC and CMHC’s • Per member per month payment to support Nurse care manager, admin support, health home director, physician consultant, BHC. • PC’s required to use BHC model and SBIRT.

• VA Programs: Three Efforts • Assigning SMI patients to a general primary care team with enhanced coordination of care with MH. • Assigning a care manager to SMI patients to ensure that the patients receive appropriate services. • Creating a full service PC presence within SMI programs.VA is implementing the medical home now and but tough to orchestrate all need services!

Primary Behavioral Health Care Initiative • Primary Behavioral Health Care Initiative • SAMHSA grant – demonstration projects to improve physical health status in SMI;64 grantees, beginning 2009. • Target audience Quadrant 4: Both high physical and high mental health risk.

• Better coordinate and integrate primary and behavioral health care resulting in: • •

Improved access to primary care services Improved prevention, early identification and

• Intervention to reduce the incidence of serious physical illnesses, including chronic disease •

Increased availability of integrated, holistic care for physical and behavioral disorders • Better overall health status of clients

PBHCI: Models developed so far None of these more than 2 years old: •Doc on site •Care management / coordination with primary care – like ACT. •Use of registry [not widespread use of computerized registry] •Wellness activities training •Behavior change!

Principles of Integrated Care for Seriously Mentally Ill Find Patients:

Track Patients:

Screening, identification and determination of medical diagnoses

Systematic follow-up and use of registry

Treat Patients:

Program Oversight and Quality Improvement:

- Evidence based treatment of medical and mental health conditions - Heath behavior change - Timely treatment adjustment

Regularly review outcomes and make adjustments to program

Nuts and Bolts

Working Together: Floor plan of the future

Cortez Integrated Healthcare: Floor Plan

Finding Patients - Routine screening (Who?, Where?) - Self referral - Psychiatrist monitoring and referral in community mental health centers

American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27:596–601

But remember… screening is just the start. You cannot fatten a cow by weighing it. ~ Chinese Proverb

Who owns the information and what will you do with it?

Tracking Patients: Use of computerized registry •This has been slow to evolve in PBHCI •But here is an example of its use in a BHC program: •Track outcome data •Prevent falling through cracks •Treat to target

Snapshot of case manager caseload outcomes

Track measurements over time, snapshot of medications and can graph outcomes.

Another view of health measurements and due dates for next measurements.

Treatments Medical Treatments Targets

Health Behavior Change Targets

Glucose control


Blood pressure

Smoking cessation

Cardiac risk reduction

Improving dietary habits

Care Manager • Facilitates patient engagement and education • Manages a caseload of patients and systematically tracks treatment response • Works closely with both primary care and mental health providers • Supports medication management • Provides brief, evidence-based counseling or refers to other providers for counseling services • Reviews challenging patients with appropriate provider • Facilitates referrals to other services (e.g., substance abuse treatment, specialty care and community resources) as needed

Working with Care Managers Who are the care managers? • RN,MA, ARNP, Case Mangers? What makes a good care manager? • • • • • • •

Organization Persistence Creativity and flexibility Enthusiasm for learning Strong patient advocate Willingness to be interrupted Ability to work in a team

Sample Medical Treatment Protocol Target



Glucose Control

FBG 80-120 HbA1C < 6.5

1) Metformin (250mg/day with dinner X 2 days, then 250mg BID for 2-3 days then 500mg BID) 2) Insulin as needed by protocol

Blood Pressure

BP < 130/80 mmHg

1) Home blood pressure monitoring 2) Protocol for starting anti-hypertensive 1) Prinzide (10mg lisinopril/12.5 HCTZ) OR 2) Atentolol 25mg

Cardiac Risk Reduction

LDLc < 100

1) Lisinopril 10mg X 2 days then 20mg Qday 2) Lovastatin as needed 3) ASA enteric coated 81 or 325 mg/day unless contraindicated

TEAMCare, Katon et al 2010

Health Behavior Change 40% of deaths in US from behavioral causes. Rates of smoking, obesity higher in poor, SMI.

Health Behavior Change Target




Behavioral activation and smoking cessation strategies OR smoking cessation program


Maintain Weight or 5% Weight Loss

DASH diet, ADA, AHA Mediterranean diet, Weight Watchers or other “healthy plan”

Physical Activity

Assess past activity and Increase current activity as brainstorm options to able to 30 min walking/day increase physical activity

Smoking Cessation

TEAMCare, Katon et al 2010

Inactivity • IN SHAPE Health Promotion Program • • • • • •

Manualized Intervention with Multiple Replications Individualized fitness and healthy lifestyle assessment Individual Meetings with a “Health Mentor” Membership Vouchers to Local Fitness Centers Group Health Education/Motivational “Celebrations“ Nurse Evaluation and Consultation

• Participants spend time each week with personal mentors working out, taking walks, in classes or working on nutrition plans. • Mentors help participants to track their progress, set goals and stay motivated. Promoting Health and Functioning in Persons with SMI: CDC - R01 DD000140 (PI: Bartels) Health Promotion and Fitness for Younger and Older Adults With SMI: R01 MH078052-01 (PI: Bartels)

In SHAPE Outcomes • Benefits for participants: • • • •

Increased participation in regular exercise Reduced waist circumference Improved satisfaction with fitness Improvement in mental health functioning and negative symptoms

• Role of Meds? Role of Dietary Component? Van Citters AD, 2010.

Smoking Cessation •

Interventions are worthwhile, don’t have to be complicated: • Unassisted quit attempt: 4-7% stop smoking. [2008 guideline] • Physician advice: 10.2% [2008 guideline] • >10 min counseling: 22% [Cochrane review]

• • • • •

Nicotine Replacement Therapy increases chances of stopping smoking by 5070% [Cochrane] Community interventions[smoke-free workplaces] - “limited evidence” for impact [Cochrane] Telephone support ( e.g., 1-800-QUIT-NOW ) effective as compared with no counseling. Counseling: Motivational Interviewing, CBT both effective. Self-help: weak effects [Cochrane and 2008 Guideline]

Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update of the United States Department of Health and Human Services.

Smoking Cessation Brief Intervention • Free online programs and information: • •

• Quit Line • 1-800-QUIT-NOW

Improving Dietary Habits • An initial weight loss goal of 5 to 7 percent of body weight is realistic for most individuals. • Many types of diets produce modest weight loss. • Options include: balanced low-calorie, low-fat low-calorie, moderatefat low calorie, low-carbohydrate diets, and the Mediterranean diet.

• Encourage a diet that reduces energy intake below energy expenditure to individual patient preferences, rather than focusing on the macronutrient composition of the diet • Explore community resources: • Example: Purdue Extension Service – absolutely free 6-8 sessions of in-home [or in, say, group home] instruction AND they cook with the patient!

Health Behavior Change Many opportunities in mental heath settings! • A huge body of knowledge and expertise in behavior change is basically unknown to psychiatrists. • A few examples of health behavior change models: •Health Belief/Health Action Model •Relapse Prevention Model •Health Action Process Approach •Motivational Interviewing

Simple Behavior Change Plan STEP ONE: Choose a tiny step. (Walk one block.) STEP TWO: Find a spot. (Every morning on my way to work.) STEP THREE: Train the cycle. (Do it every day.) STEP FOUR: Assess Outcomes. (Did it change? Any changes?)

Motivational Interviewing for Health Behavior Change Definition


• “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller and

• Demonstrated intervention for health behavior change: • • • •

Rollnick, 2002)

• • • • Adapted from slides from Kari Stephens, PhD

Substance Use/Abuse Dual Diagnosis Eating Disorders/Obesity Medical Co-morbidity (Cardiovascular health, Diabetes, Asthma, HIV treatment and more) Health Promotion/Exercise Fitness Medical Adherence Depression and Anxiety Smoking Cessation Pain

MI cowboy

C u llu m , L . T h e N e w Y o rke r. M a y 9 , 2 0 0 5 .

“Of course we can’t make you do anything you don’t want to do…But we’re all headed to Dodge City and we’d like you to join us.” Adapted from slides from Kari Stephens, PhD

Getting Started????

If you build it, they will not necessarily come… North Shore put a nurse practitioner in place  Very little business!

Why not? – Separate FQHC registration a significant barrier. – It turns out staff are needed to shepherd the transition, even in the same office suite. – All CMHC staff didn’t have message repeated and repeated and repeated… – What seems like a lot of CMHC patients is a trickle for the FQHC!

Tasks Prior to Setting Up a Program •Financial arrangements •Agreements with primary care providers •If you don’t have pre-existing relationship, they may not be that interested •Plan protocols and workflow

•Plan for evaluation •Promotion, Promotion, Promotion!

Promoting the program • PR, PR, PR • To Organizations • To Providers • To Patients

• Get your story straight! • Why should anyone care or want integration? • Why should anyone care about population health? • Need to develop tag line • “We need this to improve health outcomes!”

More PR Regional Primary Care Initiative Persons with mental illness die up to 25 years too soon due to preventable health conditions. Regional Primary Care Initiative now offers a nationally recognized program to bring needed primary medical services to our clients, right in our Merrillville and East Chicago centers. General medical care at the Regional office. Assistance for consumers in Medication management, Healthy eating, Stress management, Healthy activities, Stopping smoking, Help negotiating the medical system..

Talk to your clients and peers about engaging in this program to live longer and healthier! Sign up today by calling Olga at 219-99999

Improving Care for Comorbid Conditions Under Health Reform • Financing and insurance – Ensure a core health benefits package that covers care management and other evidence-based services. – Use Accountable Care Organizations to allow vertical integration with other components of the health care system.

• Care delivery redesign – Ensure that mental health has a room in the medical home. – Help mental health providers develop IT infrastructure and participate in health exchanges.

• Fostering prevention and promotion

Until All This Happens… Focus on principles of care! Find Patients:

Track Patients:

Screening, identification and determination of medical diagnoses

Systematic follow-up and use of registry

Treat Patients:

Program Oversight and Quality Improvement:

- Evidence based treatment of medical and mental health conditions - Heath behavior change - Timely treatment adjustment

Regularly review outcomes and make adjustments to program

Get Creative! • Find natural primary care partner • A local FQHC may be thrilled with your Medicaid population. • Other solutions by PBHCI grantees: • Hire own doc • Partner with a provider, maybe by starting BHC program, offering other consultation / support services. • Academic partners may be looking for someone just like you! • State grants – e.g., Michigan Primary Care ACT. • Capitalize on MH case management expertise.

Commit to Targets Goal


Improve tracking of health outcomes

90 % of eligible clients will have documented BMI, Hgb A1c, LDLc, and blood pressure in the last 6 months.

Improve health outcomes

Reduce by 25 % the number and % of eligible clients with a Hgb A1c > 7, a blood pressure > 140/90, or LDLc > 100.

Improve health behaviors

Reduce by 25 % the number and % of clients who are smoking. Increase by 25 % the number and % of clients who are physically active (30 minutes or more of aerobic activity such as walking at least 4 times/ week)

Spectrum of Patient Centered Collaborative Care

Mental Health in Primary Care Settings

Primary Care in Mental Health Settings

Resources For consulting psychiatrists: • AIMS Center: • NASMHPD paper: • Registry links

Resources to provide to your team: • TEAMCare: • Katon et al: change technology links • InSHAPE • xnnl=1&adxnnlx=1329165399-vPYyZl1j7wfft0t5lTGmlg •

Primary Care in Mental Health Settings References -I 1.


3. 4.

5. 6.


Lutterman T, Ganju V, Schacht L, Shaw R, Monihan K, Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003 Nasrallah HA, Meyer JM, Goff DC, McEvov JP, Davis SM, Stroup TS, Lieberman JA. (2006) Scizophr Res. 86(1-3):15-22. Low rates of treatment for hypertension, dyslipideamia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007 Oct;64(10):1123-31. Lutterman T, Ganju V, Schacht L, Shaw R, Monihan K, Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003 Tiihonen J et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 Study). Lancet. 2009;375:620–7. Griswold KS, Homish GG, Pastore PA, Leonard KE. A randomized trial: are care navigators effective in connecting patients to primary care after psychiatric crisis? Community Ment Health J. 2010 Aug;46(4):398-402. Epub 2010 Mar 5. Piatt EE, Munetz MR, Ritter C. An examination of premature mortality among decedents with serious mental illness and those in the general population. Psychiatr Serv. 2010 Jul;61(7):663-8.

Primary Care in Mental Health Settings References -II 8.




Parks J, Svendsen D, Singer P, et al (eds): Morbidity and Mortality in People With Serious Mental Illness. Alexandria, Va, National Association of State Mental Health Program Directors, Medical Directors Council, 2006 Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011 Jun;49(6):599-604. Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. N Engl J Med. 2010 Dec 30;363(27):2611-20. Collaborative care for patients with depression and chronic illnesses. Schuffman D, Druss BG, Parks JJ. Psychiatr Serv. 2009 May;60(5):585-8. State mental health policy: mending Missouri's safety net: transforming systems of care by integrating primary and behavioral health care.

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